Impact of Rural Sanitation on Water Quality and Water Borne Diseases
Manisha Khale * and Ashok Dyalchand**
Introduction
Access to rural sanitation coverage in India has been limited and has been afforded varying levels of government interest and associated funding. The first major nationwide rural sanitation programme was the Central Rural Sanitation Programme (CRSP), launched in 1986. Only limited progress was made due to systemic weaknesses in the CRSP approach. The programme was restructured in 1999 and re-launched as the “Total Sanitation Campaign” (TSC). Despite these initiatives, in 2001, the rural sanitation coverage in India was only 22 percent (Government of India census, 2001). There was another major re-launch of the programme in 2004 incorporating lessons learnt from the first five years of implementation (GOI, DDWS, 2004, 2007).
The Community Led Total Sanitation (CLTS) approach is more recent. It sprang out of work done by Kamal Kar et. al. in Bangladesh in 2004, and spread to various countries in Asia and Africa over subsequent years. The philosophy relies on energising a local community on the issue of open defecation by inducing a sense of shame, and then helping the community to tackle sanitation issues with no government or NGO funding or support (Kamal Kar, 2003, 2005).
The TSC and the CLTS are radically different in philosophy, approach and definitions of success. The TSC is a traditional “top down” regimented approach based on the allocation of subsidies for, or the direct provision of, sanitation hardware to communities. Success is measured on the basis of the number of individuals with access to toilets. The CLTS approach, on the other hand, is a subsidy free approach relying on generating a demand, and subsequent action at the local level or no direct financial aid. The definition of success is whether the entire community becomes open defecation free (ODF) or not. ((Kamal Kar, 2003, 2005)
TSC is implemented using existing national, state and rural government organisations (including Panchayati Raj Institutions). Goals are set at national and state levels and are handed down to organisations as defined levels of access to toilets. The programme is implemented at the local level with the preliminary Behaviour Change Communication (BCC) work undertaken by Panchayati Raj Institutions, and NGOs. (GOI, DDWS, 2004, 2007) Allowing individual households to choose the relevant hardware forms the basis of the physical implementation. Sliding scale subsidies are made available to households if they are below the poverty line as defined by Government of India indices. If a household is above the poverty line there is no subsidy provided. There is also a range of incentives available at the community level for the provision of community sanitary complexes and sanitation facilities in schools and anganwadis (day care centres).
The Government of India has also launched the “Nirmal Gram Puraskar” (NGP). This programme evaluates villages, blocks and districts on the basis of their levels of access to sanitation. Villages are evaluated on the number of toilets constructed rather than their ODF status. No attempts are made to assess the actual utilization of toilets.
CLTS is implemented through a very different strategy. A facilitator visits the specific village and starts by building a rapport with the community. She/he helps the village analyse the sites and levels of open defecation, and then uses techniques to generate a feeling of disgust for such practices. This methodology is known as Participatory Rural Appraisal (PRA). The facilitator then lets the community decide what, if any, action is needed and helps the community in the design and construction of low cost, simple toilets if that is what the village community decides. By conducting follow up meetings and providing support, the facilitator helps the community to become ODF through its own actions and funding. No funds are provided for sanitation, or anything else, until the village is ODF. By definition, to be ODF, everyone in the village must have access to a toilet (Kar Kamal, 2005 and Kamal Kar with Robert Chambers, 2008). At this point, the community can qualify for the NGP award.
The philosophy of CLTS is to help a community change its sanitation habits and requirements through its own efforts and desires, since this leads to long lasting and consistent changes in behaviour. There is a further expectation that if such behaviour changes do occur, over time, individual households will upgrade the initial simple low-cost toilet hardware to increasingly higher standards. There is evidence that CLTS is a more sustainable long-term model than “top down” schemes. The latter have historically had a high non-usage of provided toilets, and have shown a high relapse rate even amongst communities that demonstrated short-term behaviour changes. (Kar Kamal, 2005 and Kamal Kar with Robert Chambers, 2008)
Poor Sanitation, Fecal-oral Contamination and Diarrhoea in Children under five
Nearly half of humanity (2.5 billion people) in the world lives without access to adequate sanitation. Out of which 650 million people (65 crores) live in India. Almost one out of two persons lives without a toilet in India. (JMP UNICEF, 2008) Without sanitation facilities to safely contain and dispose of human faeces, which are the primary source of diarrhoeal pathogens, the health of a community especially children who are vulnerable is put at risk. Diarrhoeal diseases are the second leading cause of under- five child mortality, accounting for 5000 deaths a day (Progress for Children 5, UNICEF 2006 and World Health Report 2005). Human Development Report 2006 reported that around 450,000 children die of diarrhoea every year in India.
Sanitation has been included under the Millennium Development Goal 7 after the World Summit for Sustainable Development in Johannesberg in 2002. MDG 7 sets the target by 2015 of reducing by half the proportion of people without access to improved sanitation (MDG, Indian Country Report 2005). This can also have indirect impact on MDG 6 of reducing diarrhoea in children and MDG 4 child mortality.
Worldwide, an estimated 4 billion episodes of diarrhea occur annually, more than half of these among children under five. (Murray C and Lopez AD; 1996)
In developing countries, diarrhea accounts for the deaths of nearly 1.6 million children under five every year—or almost 15 percent of all deaths for that population. (World Health Organization; 1997)
Despite a decline in diarrhea related mortality, the overall incidence of diarrhea among children under five and its associated negative consequences remain almost unabated. (Murray C and Lopez AD; 1996)
More than 80 percent of the cases of diarrhea worldwide are the result of fecal-oral contamination. At the May 2002 General Assembly Special Session on Children, the United Nations reported that 6,000 children under five die every day from diseases caused by contaminated food and water—the principal causes of diarrhea. Far too many children are dying from diseases that can be prevented through access to clean water and sanitation.” (State of the World’s Children, UNICEF; 2001).
Ninety percent of the 4 billion annual episodes of diarrhea can be attributed to three major environmental causes: poor sanitation, poor hygiene, and contaminated water and food. (World Health Organization, Health and Environment in Sustainable Development).
Access to a flush or pit toilet is a very important determinant of infant and child mortality in developing countries. Factors found to be significantly associated with an increased risk of death from diarrhea include the non availability of piped water and the absence of a flush toilet Victora C, Smith P, Vaughan J, Nobre L, Lombardi C, Teixeira A et al. 1988. The unadjusted figures for neonatal, infant and childhood mortality is higher for children in households that do not have access to a flush or pit toilet, both in India as a whole and in all states. National Family Health Survey (NFHS-l) India; 1995: 201-226.
A case control study examined the impact of several environmental sanitation conditions and hygiene practices on diarrhea occurrence among children under 5 years of age living in an urban area. The following variables were found to be significantly associated with diarrhea-washing and purifying fruit and vegetables, presence of waste water in the street, refuse storage, collection and disposal, domestic water reservoir conditions, faeces disposal from swaddles, presence of vectors in the house and flooding in the lot. Heller L, Colosimo EA, Antunes CM; 2003.
Poor sanitation and water supply are generally assumed to increase the risk of morbidity and mortality from diarrhea thereby increasing the child mortality rate. Esrey et al. reported that mortality of children with improved water supply and excreta disposal facilities was found to be 0 to 81 per cent lower than that of children without the facilities. Esrey SA, Feachem RG, and Hughes JM. (1985).
Consequences of Diarrhoeal episodes in Children under five
Taking into account both mortality and morbidity, diarrhoeal disease accounted for 100 million disability-adjusted life years (DALYs) in 1990, making it the second highest disease burden in the world. (Murray C and Lopez AD, Global Health Statistics)
If lifelong disability were added to the mix, the total DALYs for diarrhea would double! (Guerrant R, et al., Updating the DALYs for Diarrheal Disease).
Frequent bouts of acute watery diarrhea seriously debilitate children. With each successive episode, a child moves further away from his/her normal weight for age, thereby greatly increasing the risk of malnutrition and impaired child development. (Pelletier DL, Frongillo EA Jr., Schroeder DG, and Habicht JP; 1995).
Children under five in India, sub-Saharan Africa, and Latin America suffer four or five episodes of diarrhea every year, resulting in permanent growth retardation and diminished learning abilities. (Guerrant R, Kosek M, Lima A, Lorntz B, and Guyatt H. 2002). Diarrhea is not only an immediate health threat to children, but can also have long-term negative effects on a country’s socioeconomic development. (Berkman DS, Lescano AG, Gilman RH, Lopez SL, and Black MM. 2002).
The Pathways of Contamination
The direct and indirect “paths” by which people come in contact with feces in their environment are well known. From the original causal agent—feces—the bacteria, viruses, and protozoa that cause diarrhea can make their way to the host via five different but often intersecting paths: (1) fluids, (2) fields, (3) food, (4) flies, and (5) fingers.
(Wagner EG, Lanoix JN, 1958).
The exposure of children to diarrhoeal disease pathogens is effectively reduced by blocking several of these paths. The most successful efforts to prevent diarrhea involve interventions to improve sanitation, improve water quality, increase water quantity, and increase hand washing, all of which have been conclusively shown to reduce diarrhoeal disease incidence in developing countries. (Curtis V and Cairncross S. 2003); Esrey SA, Feachem RG, and Hughes JM, 1985).
Access to clean water and sanitation is important not only to prevent diarrhoeal diseases but other water related diseases as well, such as ascariasis, hookworm, helminth infection, schistosomiasis, trachoma and Guinea worm. Such interventions are most effective when used in combination. (Bull World Health Organization, 69 (5): 609-621).
The editorial article by Curtis and Cairncross in the British Medical Journal based on the results of the reviews of the impact of improved water, sanitation and hygiene on diarrhoeal diseases imply that improving the quality of water supplies cuts the risks of diarrhoea by only about 16 percent and making water more available reduces the risk by 20 percent (Esrey S. et. al., 1991). Installing adequate facilities to dispose of feces reduces risks of diarrhoea by 36 percent (Esrey S. et. al., 1991) and promoting hygiene reduces risk by 35 percent (Huttly SRA et. al., 1997). These are twice as effective as improving the water quality. A recent systematic review of the impact of washing hands with soap shows that this specific practice may be three times as effective as improving water quality, cutting the risk of diarrhoea by 47 percent (Curtis and Cairncross 2003).
Purpose of this paper
This paper examines variations in access to toilets at the family level, toilet use, open defecation (OD) rates, and the impact of these on health as measured by reported prevalence of diarrhoea and worm infestation in children under the age of six in three types of villages:
1. Villages with no sanitation improvement programmes in the recent past (Proxy baseline)
2. Villages where the sanitation programmes were implemented through a Total Sanitation Campaign (TSC) strategy
3. Villages where the sanitation programmes were implemented through a Community Led Total Sanitation (CLTS) strategy.
Method
This study was undertaken in one district each of three Indian states - Maharashtra, Haryana and Himachal Pradesh. Data were collected in three villages of Maharashtra State in January and February of 2008, three villages of Haryana State in March and April of 2008, and six villages / hamlets of Himachal Pradesh State in June of 2008. Except for the State of Himachal Pradesh, the villages selected were all of similar size, with a population of between 800 to 1,400 people (using the Government of India, 2001 census data). The district administrators selected three villages from each of the chosen districts in Maharashtra, Haryana and Himachal Pradesh. Since there are six or more small revenue villages under each Gram Panchayat in Himachal Pradesh, two villages were selected instead of one from each Gram Panchayat, in this state. Of the three types of villages selected, in one the sanitation programme was implemented through a Total Sanitation Campaign (TSC) strategy, in another the sanitation programme was implemented through a Community Led Total Sanitation (CLTS) strategy, and in the third, no sanitation improvement programme had been initiated in the recent past.